In March 2010, President Barack Obama signed the Patient Protection and Affordable Care Act into law, setting the wheels in motion for sweeping health care reform. Now that the dust has settled, what are the implications for those who provide reproductive health services, as well as those who receive them?

There are a number of "truly significant" c56 hanges for family planning provision under the new health reform law, says Clare Coleman, president and chief executive officer of the Washington, DC-based National Family Planning & Reproductive Health Association. Health care reform was a hot topic at the association's April 2010 national conference.1

According to an analysis by the Guttmacher Institute, a provision of the new law expands eligibility to all Americans with a family income below 133% of the federal poverty level, which allows 16 million more Americans to join Medicaid by 2019 than would otherwise be the case.2 This is a plus for those seeking family planning services; all Medicaid recipients receive the program's guarantee of family planning services without cost sharing, along with coverage for its comprehensive package of reproductive health services beyond family planning, the analysis states.2

Expanding access to health care through the Medicaid program for those with incomes under 133% of the federal poverty level is "tremendously important," says Coleman. "Thirty-seven states will see their Medicaid programs grow under this provision, and 16 million new beneficiaries are expected to be enrolled by 2019," she says. "Recognizing the severe budget shortfalls most states are currently facing, the federal government will assume all costs of the expansion for the first five years."

States also will have the option to immediately expand Medicaid access for family planning services up to the state's eligibility level for pregnant women, says Coleman. Twenty-seven states have Medicaid family planning programs under the waiver system; in all of those states, Medicaid family planning expansions have saved state and federal dollars, says Coleman. The option also gives states an important tool to fill gaps in the health care safety net until coverage is available through increased Medicaid and private health insurance access in 2014, she observes.

Check insurance changes

Many family planning patients who are uninsured individuals might benefit from changes in insurance propelled by the new legislation.

For those individuals with incomes above 133% of poverty, the law provides them an ability to purchase private insurance coverage through the new health care exchanges, with almost all of them aided by a federal subsidy.2 Many of the plans will be required to offer a similar package of core services, according to the Guttmacher Institute analysis. While details are yet to be filled in, maternity care is included, which closes a major coverage gap in the individual and small group market. The final package is projected to include coverage such reproductive health services as contraceptive services and supplies.2Insurance plans participating in the exchanges will be required to contract with essential community providers, which include family planning centers, community health centers, public hospitals, and HIV/AIDS clinics.

An important benefit for women is the provision for all private insurance plans, inside and outside the exchanges, to cover a package of preventive and screening services for women without cost sharing. The exact package will be defined by the federal government, following a study to be conducted by the Health Resources and Services Administration.2

"Research clearly demonstrates that even nominal co-pays drastically reduce the utilization of preventive health care services, undermining key public health goals and ultimately only increasing health care costs," says Coleman. "Making an up-front investment in these services is critical to the goal of improving public health and lowering overall costs."

Young people who might have been without health coverage will see benefit from the new reform legislation. According to the Guttmacher Institute analysis, all private plans that provide dependent coverage will be required to make it available for unmarried adult children younger than age 26. For those who might be at risk for unplanned pregnancy or sexually transmitted infections (STIs), this provision, which goes into effect later in 2010, represents another important avenue for care.2

One important component of the health care reform legislation involves the inclusion of essential community providers in state-based exchanges, says Coleman. While expanding coverage is a critical component in health care reform, it is imperative that poor and low-income patients have access to health care providers, she states.

"Across the country, millions of Americans currently receive high quality, culturally competent health care from safety net providers, including publicly funded family planning health centers and community health centers among others," Coleman says. "To ensure that the most vulnerable have access to the providers who best meet their needs, it is imperative that health plans participating in the state exchanges work with the safety net provider community."

When combined with long-term investments in the health care workforce, the inclusion of safety net providers in state exchanges will help mitigate the growing provider shortage in preventive and primary health care, Coleman says. Including safety net providers greatly increase the odds that the newly insured patient population could see a provider on day one and that that provider could be reimbursed for providing that care, she states.

The new law includes $1.5 billion over five years to support maternal, infant and early childhood home visiting programs, with a focus on high-risk families. It also boosts the rebates pharmaceutical manufacturers must offer to state Medicaid programs for brand-name and generic drugs and in the discounts offered to safety-net providers, including Title X–supported family planning centers, under the 340B Drug Discount Program.

Significant new funding is included for community health centers, which provide family planning services and other basic reproductive health, according to the Guttmacher Institute analysis.2 The legislation also establishes a dedicated $50 million yearly funding stream for school-based health centers, many of which provide contraceptive care.

Providers see benefits

How might the new legislation be of direct assistance to health care providers? The reform package includes several dozen programs designed to bolster the health care workforce through loan forgiveness and provider training programs, some of which are relevant for family planning providers, according to the Guttmacher Institute analysis.

Under the new law, certified nurse-midwives (CNMs) have achieved equitable reimbursement for their services under Medicare. As of Jan. 1, 2011, the CNM reimbursement rate will increase from 65% to 100% of the Medicare Part B fee schedule, according to the American College of Nurse-Midwives (ACNM).

"Payment equity for certified nurse-midwives under Medicare will increase the availability of much-needed midwifery services for women, including maternity care, family planning, and primary care services," says Melissa Avery, CNM, PhD, FACNM, FAAN, ACNM president. "We anticipate Medicaid and other payers will also provide equitable reimbursement to midwives, thus improving the opportunity for both midwifery practices and for other employers to hire midwives."

Challenges lie ahead

While several strides have been made in enacting the health care reform legislation, family planners need to be mindful of challenges that lie ahead, Coleman advises. The current economic downturn has exacted a heavy toll on publicly funded family planner facilities, which had struggled prior to the recession, she notes. On top of problems with staff shortages and unpredictable cost increases, family planning clinics have increased demand for services, combined with public funding cuts.

"In my own experience running a publicly subsidized health system, I had to cut hours and staff to control costs more than once, leaving the system ill-prepared when patient demand began to grow," Coleman says. "Patients are less able to cover their share of costs, private donations are down, and state budgets will get worse before they get better. A big question is: Can the family planning public health system make it to health care reform?"

Many questions will be raised on how public health service programs such as Medicaid and Title X integrate with health insurance reform, states Coleman. Patients being seen under Title X or a Medicaid waiver today might move to traditional Medicaid or a state-based exchange, depending on income. This opens the door to problems with continuity of care, Coleman observes.

"Patients need consistency in their contraceptive care, and the programs aren't designed to work together well," she notes. "I can tell you from experience that it's frustrating for patients and a real hassle for administrators."

There is concern that support for Title X and other Public Health Services Act programs might diminish under the current reform legislation, says Coleman. The Massachusetts experience with health care reform has shown family planners that careful attention needs to be paid as laws are enacted and regulations are written to ensure public health programs are not penalized.

"In Massachusetts, since the passage of universal coverage, state family planning dollars have shrunk by nearly 70%, and the state has entirely defunded the STI clinic system," Coleman says. "Now, some patients are waiting for gynecological appointments, and there are safety-net systems in crisis." [Editor's note: Contraceptive Technology Update reported on the historic health care reform legislation in a special March 23, 2010, e-mail bulletin. If you would like to sign up to receive future bulletins, contact Customer Service at customerservice@ahcmedia.com or (800) 688-2421.]